It’s Your Choice
Approximately 50% of women treated with estrogen (especially pellet implants) experience uterine bleeding. If a menopausal patient experiences bleeding, she should notify her gynecologist or primary care physician for evaluation, which may include a vaginal ultrasound and endometrial biopsy. The primary cause of bleeding is continuous uterine stimulation by estrogen. Testosterone does not stimulate the uterus, so no progestin is required. Estrogen also stimulates breast tissue. Estradiol pellets may increase the risk of breast cancer.* Higher estrogen levels (in the second half of the menstrual cycle) are necessary for pregnancy, but most women feel better with lower estrogen levels.
Why Choose Testosterone Pellets Alone?
Almost all menopausal symptoms, including hot flashes, are relieved with testosterone pellets alone. A 1985 study by Sherwin compared testosterone alone, testosterone with estradiol, estradiol alone, and placebo. The group receiving testosterone alone showed the best outcomes (somatic, psychological, and total scores). The groups receiving estrogen alone or placebo performed the worst. As expected, higher testosterone levels correlated with better responses. Testosterone is the primary substrate for estrogen production in the brain, bones, vascular system, breast, and adipose tissue—not circulating estradiol. Some physicians may not understand this and insist on estrogen therapy. Unlike estrogen, testosterone alone may lower the risk of breast cancer.
Excess Estrogen Risks
Excess estrogen can cause anxiety, weight gain, abdominal fat, breast tenderness, emotional lability, PMS-like symptoms, and mood swings. Long-term exposure to higher doses of stronger (continuous) estrogens or synthetic progestins may increase the risk of breast cancer. Environmental exposure to estrogen-like chemicals further compounds this issue.
Aromatization and Inhibitors
Some women (and men) convert too much testosterone to estradiol, which can reduce testosterone’s beneficial effects. An aromatase inhibitor, such as anastrozole, may be prescribed to prevent this. Patients, including breast cancer survivors, may receive testosterone-anastrozole combination implants.
Vaginal Estrogen Delivery
If needed, vaginal estrogen (as a cream or tablet) is one of the safest and most effective delivery methods. It treats vaginal symptoms like dryness and discomfort, as well as urinary symptoms such as urgency, frequency, hesitancy, nocturia (nighttime urination), and incontinence. Estriol (E3) is less stimulatory to breast tissue and the uterus than estradiol and may be combined with progesterone (and/or testosterone) in a single cream. The vaginal cream is typically used daily for 14 days, then 2–6 times per week as needed. Once vaginal tissue is healed and symptoms resolve, the cream or tablet may be discontinued.
Testosterone Benefits and Lifestyle
Testosterone increases muscle mass and bone density while reducing fatty tissue. However, a diet high in refined carbohydrates or sugars can hinder weight loss and other benefits of testosterone pellet therapy. Diet and exercise are critical for health and well-being. Certain prescription medications may also interfere with testosterone pellet effects. For additional information, refer to the ‘Troubleshooting’ handout.
Progesterone Benefits
Progesterone may be used with testosterone to help women experiencing sleep difficulties, hot flashes, tension, or anxiety. Both testosterone and progesterone have beneficial effects on the brain and nervous system.
*Million Women Study THE LANCET, Vol 362, August 9, 2003. Increased breast cancer risk with estradiol implants, RR 1.65
